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Goal’s for Today Lagophthalmos Blepharospasm Blepharoclonus Myokymia

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Presentation on theme: "Goal’s for Today Lagophthalmos Blepharospasm Blepharoclonus Myokymia"— Presentation transcript:

1 Goal’s for Today Lagophthalmos Blepharospasm Blepharoclonus Myokymia
Trichiasis Poliosis Madarosis Ingrown Cilia Dermatochalaisis Blepharochalaisis Herniation of Orbital Fat Papilloma/Verruca Cutaneous Horn/Tag Seborrheic Keratosis Keratocanthoma Dermoid Sebaceous Gland Cysts Sudoriferous Cysts Nevus

2 Dear Dr. Golden Eye: My friends say that I am super hyper and that I do not like things to pass me by. Recently, my new girlfriend took a picture of me when I was sleeping and posted the picture below. Now that I think about it, my eyes do feel a bit irritated. What’s going on? What are the common causes of my condition? Clue me on your evaluation of me? What can you do for me (treatment / management)? Signed: Peek-a-boo

3 Lagophthalmos Inability to completely close the lids; remain open 2-5mm Significance Usually results in exposure of the globe causing epithelial dessication; c/o dry, scratchy eye, possibly secondary infection and/or corneal ulcers. Sterile ulcers can result

4 Common causes/classification
Paralytic of orbicularis (CN VII palsy) - Bell's palsy Orbital Corneal apex more anterior than normal (keratoconus) Differential diagnosis includes: Globe displaced forward (retrobulbar mass, thyroid disease) Larger than normal axial length Shallow orbit (rare)


6 Neurogenic Stimulation of retractors (Mueller's muscle) Hyperthyroidism (Grave's disease) is most common cause Mechanical Scarring Active lid disease Physiological or nocturnal lagophthalmos

7 Signs and symptoms During sleep lids not in apposition -> tear film evaporation - epithelial dessication Symptoms of dry, scratchy, irritated eye upon awakening Look for punctate epitheliopathy across inferior cornea - this may not be present or may be positioned elsewhere Check for Bell's phenomenon (although this is probably unrelated to position of globe during sleep)

8 Check passive lid closure, may need to recline patient
Ask spouse if patient sleeps with eyes open Check whether blink is complete. Check blink rate Evaluate for anterior segment diseases, especially blepharitis

9 Management Mild symptomatic lagophthalmos Artificial tears PRN (Q1H to QID recommended) Bland ophthalmic ointment HS if needed (Lacrilube) Moderate Artificial tears PRN, ophthalmic lubricants hs Tape from cheek to brow/forehead while pulling lower lid up Moisture chamber (Saran Wrap sealed with tape - Transpore surgical tape or Dermocel)

10 Use broad spectrum antibiotics (TABLES on pages 14 and 15) if significant corneal epithelial dessication or damage (to prevent secondary infection) Surgery (tarsorrhaphy) Must have regular follow up to rule out infection or serious drying; every 3 months or more frequently.

11 Blepharospasm Involuntary contraction of orbicularis
Generally bilateral and symmetric, though onset may be unilateral Older individuals, females > males

12 Severity progresses over 6 months to 3 years
Does not occur during sleep Fatigue and stress may increase intensity Unknown cause, possibly due to chemical imbalance and/or misfiring of neurons of basal ganglia

13 Signs and Symptoms Involuntary lid closure
Facial muscles (jaw, tongue, lower face, mouth) May be so severe as to cause secondary tempero-mandibular joint syndrome (TMJ) Various sensory "tricks" may suppress the severity of the contractions Commonest is placing a finger at the lateral margin of the orbit Others: coughing, yawning, talking, humming, or singing

14 Differential diagnosis very complicated
Ocular disease Myokymia Tardive dyskinesia caused by antipsychotic medications (Prolixin, Haldol) Various neurological disorders Functional (hysterical)

15 Treatment Counseling since patient is quite self-conscious
Counseling for depression since many activities of daily life and work are interrupted Medications interfering with nerve conduction are variably, but not consistently successful

16 Botulin A toxin injections
Interferes with neural transmission Relief of symptoms averages 3 months Typical side effects: Ptosis Subcutaneous hemorrhage at injection site Dry eyes Double vision Exposure keratitis Side effects resolve as toxin wears off

17 Onset of action after injection: 2-3 days
Full benefit: 5 days Peak effect: 2-4 weeks Duration of clinical benefit: 3-4 months, but can vary from few weeks to 6 months

18 Surgery Myectomy and/or partial neurectomy Myectomy removes squeezed muscles in upper lid, eyebrows, forehead, and base of nose Neurectomy consists of resection and removal of small facial nerve branches innervating orbicularis Referral to national support groups and organizations for individuals with blepharospasm

19 Blepharoclonus Exaggerated reflex blinking characterized by increased blink rate or length of lid closure time Causes Often no cause found Commonly in children 5-10 years old with no apparent cause but parents are distressed - this is most common presentation

20 Evaluation Management
Workup is the same as for blepharospasm - rule out anterior segment disease, irritation, fb, etc.; complete eye exam Management Reassurance - (self limited disorder) Consult with neurologist if desired Numerous surgical procedures to interrupt CN VII have been tried

21 Myokymia Eyelid tic or twitch
Mild to moderate fasiculations of orbicularis Signs and symptoms Patient aware of annoying twitch Unilateral More often lower lid Examiner generally sees nothing wrong

22 Multiple causes Fatigue, lack of sleep Stress, anxiety, tension
Anterior segment irritation Light dazzle Anemia, nutritional deficiency Excessive use of tobacco or alcohol Anticholinesterases used therapeutically (physostigmine, neostigmine, echothiophate) Rare: M.S., myasthenia gravis, trigeminal neuralgia


24 Treatment Reassurance Rule out irritation, infection, inflammation
Consultation with family MD or psychologist to evaluate stress, tension, etc. Pharmacological treatment Topical antihistamine eyedrops (SEE TOPICAL ANTIHISTAMINE TABLE on page 21) QID x 1 week BID x 1 week Re-eval

25 Stubborn cases may warrant oral quinine, mg, QD to TID; CONTRAINDICATED in pregnant women, since increases risk of abortion Oral antihistamine Benadryl

26 Dirty water = tonic water with lime
Drink prn

27 Trichiasis Lashes touch globe Causes Entropion Growths on lid margin
Lid trauma Scarring of conjunctiva (trachoma, Stevens-Johnsons syndrome) Blepharitis is most common

28 Signs and symptoms Discomfort or pain, foreign body sensation, injection Chronic tearing due to foreign body sensation May traumatize the epithelium corneal epithelial defects - infections, ulcers damage and scarring of conj or cornea Can cause vision loss due to corneal scarring

29 Evaluation Find the underlying cause of the trichiasis if possible - blepharitis is a common underlying cause Careful slit lamp evaluation for both trichiasis and epith damage Use fluoroscein - check for staining; epithelial damage

30 Management Epilate in-turning lashes Forceps or epilation tweezers Soak tools in zephiran chloride solution (1:3OOO) with anti-rust tablets added Can anesthetize lid Firmly grasp lash at its base and pluck Do not clip lashes


32 Lashes grow back Children: 2-4 weeks Adults: 4-8 weeks Cauterization of follicles generally gives poor results Electrolysis destroys lash follicles; successful but quite painful

33 If > 1/3 of lashes are turned in, surgery is warranted rather than electrolysis
Cryosurgery Argon laser photocoagulation Regular use of ocular lubricants Q1H to QID Prophylactic broad spectrum antibiotic coverage

34 Poliosis Whitening of lashes Usually due to staph blepharitis
Vitiligo is not due to staph If both poliosis and vitiligo evaluate internal ocular health (c/o uveitis), if negative get dermatology consult

35 Madarosis Lash loss Causes Very common cause is staph blepharitis
Trichotellomania (neurotic pulling of lashes)

36 Evaluation Look for any evidence of staph blepharitis
Inquire about history of infection…eg Chicken Pox Rule out anterior segment disease of any kind (especially staph)

37 Management Treat blepharitis if present
Could photodocument to monitor therapy If caused by trichotellomania seek psychological counseling mascara use to minimize pulling

38 Ingrown Cilia Eyelash grown into the epidermis of the lid
Can be directed against globe (trichiasis) may have foreign body sensation Look for more than a single ingrown cilia Look for cause, lid trauma and scarring

39 Management Cut lash near follicle Remove distal portion of lash
Epilate remainder of lash Prophylaxis with antibiotic *

40 Dermatochalaisis Redundancy of skin of the upper lid such that it drapes downward over lid margin. May look like ptosis - hold the redundant skin flap up Middle aged to elderly patient; bilateral May be familial tendency May have herniation of orbital fat through the orbital septum causing puffy, "swollen“ appearance

41 Evaluation Usually quite easy to notice and diagnose (just "baggy" eyelids) Watch for true ptosis and for lid edema Management If no trichiasis and no field loss the problem is cosmetic only - reassure the patient If trichiasis, treat it. (Consider surgery - cryo, electrolysis, etc.) *

42 If field loss and desire to obtain cosmetic improvement, do a careful formal visual field evaluation with and without lids held to document functional vision defect (10˚ difference in VF loss). Insurance needs this in most cases to allow a claim for blepharoplasty Surgery - blepharoplasty remember VF necessary with and without lid held to obtain insurance funding Referral to oculoplastic specialist or cosmetic surgeon


44 Blepharochalaisis Younger to middle aged patient with baggy lids secondary to recurrent swelling of lids due to recurrent inflammation or edema These recurrences of edema result in stretching of periorbital skin, loss of elasticity

45 Superior lid drapes over lid margin in many cases
May mimic ptosis. Be sure to rule out true ptosis. Note that a ptosis (not of neurogenic origin) can result from damage to the levator aponeurosis. May be some cases with familial tendency


47 Evaluation Rule out active cause, i.e. lid mass, edema, inflammation Rule out ptosis Look for underlying cause - recurrent edema due to allergy, high BP, kidney disease

48 Management Treat any active cause Cool compressed during swelling may help to decrease Steroids usually not helpful Consult with physician may help to rule out allergic disease, cardiac or renal diseases if suspected

49 If cosmetically displeasing to patient - VF's and referral to plastic surgeon particularly oculoplastics specialist for blepharoplasty May need medical consult to determine cause of recurrent edema, i.e., rule out cardiac, renal causes and angioneurotic edema

50 Herniation of Orbital Fat
As orbital septum atrophies with age orbital fat herniates through small dehistences resulting in a soft mass usually located in upper lid medially May get referrals to evaluate "tumor“ Occurs in elderly (secondary to weakening of orbital septum involutional change) Presents as localized (inner canthus) soft, spongy mass within lid, anterior to tarsal plate


52 Evaluation Generally easily differentiated from lid or orbital growth (or lid edema) Pressure to globe results in further herniation of orbital fat in front of the septum Management Reassure patient Cosmetic surgery, if desired Excision of orbital fat plus blepharoplasty for dermatochalaisis if present

53 Papilloma Benign Epithelial Tumor
A common benign overgrowth of the epidermal portion of the skin of the eyelid (mainly the squamous epith) Can have vascular core Benign growths but varied appearance Malignancies may look like these but are generally clinically differentiated on appearance May be caused by virus (if so called verruca); more common in young Can have numerous presentations; can be pigmented, variety of colors

54 Types Non-viral Usually in elderly Viral Verruca Verruca is a form of papilloma Verruca plana - flat top Verruca vulgaris - angular, raised, broad stalk Verruca digitala - narrow stalk, cauliflower-like


56 Signs/symptoms Usually asymptomatic Growth Viral - fairly quick Non-viral-slow Color Various colors Surface usually rough (keratinized epithelium) but may be smooth, not eroded, ulcerated

57 Can be slowly growing, have vascular core, do not usually erode in center. Usually near lid margins at mucocutaneous junction Vascular core

58 Evaluation Rule out neoplastic growth, if possible, by looking for the following: Look for rapid growth, color change If on lid margin, no cilia at the location Bleeding highly unlikely unless papilloma is traumatized Vascularization - not present on surface of papilloma

59 Surface is often rough but not eroded or ulcerated
Surface is often rough but not eroded or ulcerated. Papilloma can occasionally outgrow blood supply resulting in keratinization or necrosis -> erosion, ulceration

60 Management Generally no treatment indicated, reassure Cosmetic treatment only if desired (excision) Can produce local lash misdirection and resultant trichiasis Easily excised with scissors if pedunculated. If large or flat, refer for surgical excision

61 Refer to dermatologist or ophthalmologist if highly suspicious or take photos and follow up in one month If new lesion, carefully evaluate for evidence of malignant characteristics; photograph and follow-up in one to three months If old, follow up yearly

62 Excision techniques Scissors/scalpal technique i) Scissors or scalpal ii) If base is small, clean area with alcohol wipe iii) Anesthetize with topical proparacaine for > 1 minute

63 iv) Grasp top with forceps and lift
v) Cut base with scalpal or scissors vi) Curved scissors are best vii) Apply pressure for bleeding viii) Cover with antibiotic ointment (TABLE page 14) ix) Follow up in one day

64 Chemical technique i) Clean area with alcohol wipe ii) Topical anesthetic iii) Surround papilloma with petroleum jelly iv) Apply bichloroacetic acid to wooden tip of cotton swab - apply to lesion v) Should turn lesion white immediately, later darkens, scab falls off in about one week




68 Verruca (Wart) A papilloma in which papilloma inclusion bodies have been seen in the epith cells. Possibly all papillomas are viral in origin - caused by the human papilloma (wart) virus Viral papillomas tend to occur in children and young adults Transmission by direct or indirect contact and autoinoculation

69 Management Spontaneous regression is likely - reassure and wait Treat any associated conjunctivitis or keratitis with goal to prevent secondary bacterial infection Excisional biopsy can be performed but can be followed by the spontaneous appearance of multiple viral papilloma Cryotherapy should accompany excision if viral etiology suspected

70 Cutaneous horn or tag Form of papilloma probably, although may be keratinized Management Easily excised (see management of papilloma)

71 Seborrheic keratosis (not actinic keratosis)
Benign, epithelial growth common in middle aged to older (some in children) Common on trunk and head Can occur on eyebrow and lids Sharply defined, slightly elevated, brown, plastered on lesions, brownish color - like a "brown plaque" on the skin

72 Important point looks like it is tacked on or stuck onto surface of skin. Little invasion into epidermis, none into dermis Significance Not pre-malignant (actinic keratosis is) Management Excision if desired Easily removed for cosmetic reasons

73 Keratoacanthoma Pseudocarcinomatous hyperplasia - benign growth
Exposed usually hairy regions (such as head, face) of skin Middle aged or older, usually 50-70 Usually Caucasian Grows rapidly x 2-6 weeks then involutes in a few months or year Maximal size usually 1-2 cm


75 Appearance Raised lesion initially - dome-shaped nodule with central core like molluscum contagiosum Has central umbilicated apical region (composed of keratin) in a crater-like excavation Has elevated rolled borders. Mimics sq. cell ca and molluscum contagiosum

76 Grows rapidly to 1-2 cm with pore expanded to display keratin filled crater
Growth stops, keratin plug is discharged leaving a pit. Mimics squamous cell carcinoma Significance Spontaneously regresses by involution but very often mistaken for squamous cell. Because of this appearance, usually excised during phase of involutional regression

77 Management Reassure Photograph if unsure and close follow-up Excision if cosmetically desired Excision should be strongly considered because: Most patients prefer not to wait for regression because of the poor cosmesis of these growths BCC and SCC can (rarely) occur along the edges

78 Excision and biopsy (all excised material should be biopsied) is recommended because of resemblance to SCC and BCC BCC and SCC can (rarely) occur along the edges Recurrence Recurrence after excision is rare so if recurrence occurs, it was almost definitely BCC or SCC, not keratoacanthoma

79 Dermoid Benign Cystic Lesion
Choriostomas, not neoplasms Choriostoma arises during development from location of the lesion Dermoids are congenital, developmental anomalies Probably groups of surface ectodermal cells entrapped during development along lines of embryonic closure

80 Appearance Tend to be cystic in nature - "dermoid cyst“ Usually superior temporal in location; usually adherent to periosteum of orbit Skin slides over surface easily

81 Evaluation If dermoid is noted look for other congenital anomalies Goldenhar's syndrome-dermoids on surface of globe often accompanied by lid coloboma and appendages on ears Management Can be removed if desired for cosmetic reasons


83 Sebaceous gland cysts Cysts in the glands of Zeiss (along lid margin) and/or in larger sebaceous glands (near eyebrows) Very common Many possible locations: scalp, face, ears, back, axillary regions

84 Types Comedo (blackhead) Keratin plaque in follicle Milia (whitehead) Small whitish, slight elevated, cyst of the pilosebaceous gland On skin of lid, usually in groups

85 Appearance Painless, benign, slow progression Firm, rubbery, rounded, often moveable, yellowish or whitish color Depth: Superficial (epithelial) - tend to be smaller < 10 mm Subcutaneous (epidermal) - tend to be large < 20 mm

86 Management Reassure, benign but can be removed for cosmetic reasons Excision of superficial cysts – technique a) Clean area with alcohol wipe b) Apply topical anesthetic for ~ 1 minute c) Incise with 18 to 27 gauge needle

87 d) Express contents e) Apply pressure for bleeding f) Cover with Polysporin ung g) Follow-up in 1 day Surgical excision for larger, deeper cysts

88 Sudoriferous cysts Elevated rounded lesions caused by blockage of the gland of Moll Common Appearance May be < 2 mm in diameter Localized at lid margin Usually painless Usually cause no problems Cystic nature apparent in indirect/proximal illumination

89 Management Reassurance, benign Can be excised easily - technique a) Clean area with alcohol wipe b) Anesthetize surface for minute c) Lance with 18 to 27 gauge needle d) Express material e) Cover with Polysporin ung f) Follow up in 1 day


91 Nevus (freckle) Benign melanotic lesions
Overgrowth of melanin-containing cells in skin Can change with time and remain benign, however change ALWAYS suggests malignancy Flat, brownish, well defined borders

92 Types Junctional nevi a) FLAT or only slightly elevated b) Smooth surface c) Uniform light to medium brown d) Symmetrical borders e) Rarely become malignant

93 Compound nevi a) Somewhat elevated, more so with age b) Flesh colored or brown c) Smooth or warty surface d) Symmetric, uniformly round or oval

94 Dermal nevi a) Raised, dome-shaped b) Brown or black, lighter with age c) Smooth or warty surface d) May have telangiectatic vessels on surface e) Exposed and prone to trauma from clothing

95 Guidelines for recognition of normal nevi
a) (A)symmetrical: symmetric, matching halves if "folded" together; round or oval b) Borders: regular, usually quite distinct c) Color: uniform within lesion, varies from very light brown to black

96 d) Diameter: < 6 mm e) Elevation: fairly flat f) Remain uniform in size, shape, and color ABCDEF

97 Evaluation Careful history to document onset and progression Size it!!! If any doubt photodocument and follow very closely or better yet dermatology consult Management Photograph carefully Re-evaluate based on degree of suspicion Only biopsy can definitely rule out melanoma. Any change demands a biopsy.

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